SCHEDULE: ETHICAL & LEGAL, & SOCIAL ISSUES IN MEDICINE, 1985 27 August 1300 -1420

1430-1600

Introduction to the Course E. Howe, M.D., J.D./P. Mitchell/A. Jankowski Discussion Groups*

3 September 1300 -1350

Infants with Defects, Religion, Microallocation J. Childress, Ph.D.

1350 -1430

Military Triage - R. Rozin, M.D.

1440 -1455

The Student/Patient Relationship D. Cohen, LCOL,USAF,MC

1500-1600

Discussion Groups*

10 September 1300 -1350

The Student & Doctor/Patient Relationship E. Pellegrino, M.D.

1400 -1450

FILM: The Case of Dax Cowart

1500 -1600

Discussion Groups*

17 September 1300 -1350

Deciding to Live or Die R. Veatch, Ph.D.

1400 -1420

D. Smurr

1430 -1600

Discussion Groups*

24 September 1300 -1420

The Doctor/Patient Relationship in the Military R. Bellamy, COL,MC,USA/E. Dolev, M.D./C.Llewellyn,COL,MC,USA

1430 -1500

FILM: (1) The Silent Scream

1500 -1600 Discussion Groups* Lectures will be held in Lecture Room D, Building C *Discussion group will be held around tables in cafeteria marked by letter

-21 October 1400 -1450

Abortion and the Fetus P. King, J.D.

1500 -1600

Discussion Groups*

8 October 1400 -1450

Genetic Screening and Counseling R. Murray, M..D.

1500 -1600

Discussion Groups*

15 October 1400 -1415

Experimentation in the Military H. Holloway, COL, MC, USA

1415 -1600

Experimentation on Animals Film, Class Discussion and Panel R. Simmonds, DVM, Moderator J. Fletcher, Ph.D., E. Howe, M.D., J.D., Panelists

22 October 1400 -1450

"A Philosopher on the Wards" S. Gorovitz, Ph.D.

1500 -1600

Discussion Groups*

29 October 1400 -1415

"Coercive Influences in Medicine" R. Rahe, CPT,MC,USN

1420 -1450

Dramatic Presentation: "Frankenstein" Jon Spelman

1450 -1500

INTERMISSION

1500 -1530

Frankenstein (Continued)

1530 -1600

Panel - E. Dolev,M.D./C.Llewellyn, COL,MC,USA and Class Discussion

SESSION I: TUESDAY, AUGUST 28, 1985 27 Aug

Objectives:

1300-1420

INTRODUCTION

1430-1600

DISCUSSION GROUPS*

Edmund G. Howe, M.D., J.D. Pat Mitchell Anthony Jankowski

1) To understand course goals and requirements 2) To acquire basic knowledge of ethical reasoning and of the distinction between deontological and utilitarian values 3) To learn the value of listening to persons' experience in order to enhance clinical sensitivity 4) To identify issues and arguments related to the tretment of infants born with severe birth defects 5) To identify issues involved in discussing religious views with patients 6) To identify problems in deciding how to ration scarce resources 7) To identify ethical concerns related to military triage

Subscription Form:

The Hastings Center Report

Required Reading: 1) The Final Anticlimatic Rule on Baby Doe. Murray, Hastings Center. Rep.5-9, June, 1985 *Attendance is mandatory.

-2Recommended Readings: 1) Birth-Defect Dilemma: Students Given Taste. US Medicine, April 15, 1981, p. 25. 2) Down's Victim Gives Medical Students a Special Lesson. The Baltimore Sun, July 7,1985, Section B, p. 1. 3) Parental and Community Response to the Birth of a Down's Syndrome Child. 4) Moral and Ethical Dilemmas in the Special Care Nursery. Duff and Campbell, NEJM, 289(17): 890-894, 1973 (On Reserve). 5) The New Life-or-Death Choices. Klein, The Washington Post, August 29,1978, p. 19. 6) Counseling Parents of Infants with Down's Syndrome. Pueschel and Murphy, Postgraduate Medicine 58(7): 90-95,1975. 7) Triage - Who is Sorted and Why? Joy, Hard Choices, 1980. 8) Triage in Medical Practice: An Unacceptable Model? Bell, Soc Sci & Med 15: 151-156,1981. 9) Doctor's Dilemmas. Gorovitz, Preface and Ch. 1.

SESSION II: TUESDAY, 3 SEPTEMBER 1985 3 Sept

1300-1350 1350-1430 1440-1455 1500-1600

Objectives:

Infants with Defects, Religion, Microallocation J. Childress, Ph.D. Military Triage - R. Rozin, M.D. The Student/Patient Relationship D. Cohen, LCOL, USA, MC Discussion Groups*

1) To gain greater understanding of issues discussed in last week's discussion groups 2) To explore the nature of the physician-patient relationship and its theoretical basis 3) To explore conflicts regarding truthtelling and confidentiality 4) To identify potential difficulties in students' attempting to respect patients' interests in a teaching environment 5) To discuss issues and arguments related to medical students' roles such as whether or not to tell patients one is a student, how much to tell patients about one's prior experience in performing procedures; and what to do when one believes that a member of the house staff or an attending physician is acting unethically

Required Reading: 1) Legal Aspects of Critical Care Pharmacology. Howe, from the Pharmacologic Approach to the Critically Ill Patient, 1983 Recommended Readings:

*Attendance is mandatory.

1) Terrified Consent. Coleman, Physician's World, May1974 2) Ethical and Cultural Dimensions of Informed Consent. Cross and Churchill, Annals of Int. Med. 96: 110-113, 1982 3) The Limits of Confidentiality. Bok, Hast. Cent. Rep. 24-31, Feb, 1983 (On Reserve) 4) A Student Examines Life on the Wards, Hoffman 5) Bad News About Doctors' Bad News. Restak, Washington Post, B1, July 14, 1985

-2Required Reading (Cont.) 6) Tricyclic Antidepressant Poisoning and Prolonged External Cardiac Massage During Asystole. Orr, Bramble, British Medical Journal 283:1107-1108, 1981 (On Reserve) 7) Couple Endures the Unbearable: A Child Only Technically Alive. Barringer, Washington Post. (On Reserve) 8) Doctor's Dilemmas, Gorovitz, Chps. 2 & 3

SESSION III: TUESDAY, 10 SEPTEMBER 1985 10 Sept

The Student & Doctor/Patient Relationship E. Pellegrino, M.D. 1400-1450 FILM: The Case of Dax Cowart 1500-1600 Discussion Groups*

Objectives:

1) To gain greater understanding of issues discussed in last week's discussion group 2) To discuss aspects of telling patients and their families the truth about terminal illness 3) To discuss legal and ethical considerations in regard to decisions to forego life sustaining treatment 4) To discuss specific approaches to assessing patient's competency to refuse treatment and ethical considerations when making this assessment 5) To discuss issues relating to the withholding of treatment from incompetent patients

Required Reading:

1) Ethical Decisions in the Case of a Patient Terminally Ill with Metastic Cancer. Lo and Jonsen, Annals of Internal Med. 92: 107-111, 1980 2) Law/Debate on the Boundary of Life. Time, April 11, 1983, p. 68-70

Recommended Readings:

1) A Happy Life Afterward Doesn't Make Up For Torture. The Washington Post, June 26, 1983, D3 2) When Suicide Prevention Becomes Brutality: The Case of Elizabeth Bouvia. Annas, The Hastings Cent. Rep. April 1984, pp. 204 3) Allowing the Debilitated to Die. Hilfiker, NEJM 308: NEJM 308: 716-719, 1983. (On Reserve) 4) Cancer Patient Gets to Die "Peacefully". Smith, The Washington Post, March l, l 1985, c 1 5) Final Requests: Preparing for Death. Morse, The Washington Post, July 15, 1985, D5 6) Patient Sues to Block Amputation of Leg, The Washington Post, June 2, 1984 7) Judge Rules for Reluctant Patient, The Washington Post, June 6, 1984

-28) In the Matter of Bertha Harris, 477 A 2nd 724 (1984) (On Reserve) 9) Tests of Competency to Consent to Treatment. Roth, Meisel and Lidz, Am J. Psychiatry 134: 279-284,1977. (On Reserve) 10) The Physician's Role in the Events Surrounding Patient Death. Tolle, Girard, Arch. Intern Med. 143: 1447-1449,1983. (On Reserve) 11) Doctors' Dilemmas. Gorovitz, Ch 4

SESSION IV TUESDAY, SEPTEMBER 17,1985 17 Sept

1300-1350

Deciding to Live or Die R. Veatch, Ph.D.

1400-1420

D. Smurr

1430-1600

DISCUSSION GROUPS*

Objectives:

1) To gain greater understanding of issues discussed in last week's discussion groups. 2) To gain familiarity with ethical issues of particular concern for military physicians. 3) To appreciate practical aspects of pursuing ethical beliefs in a military context. 4) To discuss values and possible conflicts between military physicians’ duties to the military, patients, the medical profession, and humanity.

Required Reading:

1) Medical Ethics: Are They Different For The Military Physician. Howe, Mil. Med. 146: 837-841, 1981. 2) “Warfare”.Vastyan, in the Encyclopedia of Bioethics, Reich, Ed., New York, The Free Press, 1977. 3) AIDS Virus Test for U.S. Military is Considered. Engel, The Washington Post, July 31,1985, Al. 4) AIDS Seen Bankrupting Military Medical System/ Navy Forces Out Victims Who Admit Homosexual Contact. Smith, Navy Times, August 26,1985, p.4.

Recommended Readings:

1) The Psychiatrist's Role in War. Veatch, in Case Studies in Medical Ethics. Cambridge, Mass.: Harvard University Press, 1977. (On Reserve) 2) Contrasts in Combat Casualty Care. Bellamy, Military Medicine 150: 405-410, 1985. (On Reserve) 3) The Psychiatrist as Double Agent. Callahan, Gaylin. The Hastings Center Report 2/74, pp. 12-14. (On Reserve) 4) What's an FBI Poster Doing in a Nice Journal Like That? Gaylin, Moral Problems in Medicine. Ed., Gorovitz, Englewood Cliffs, New Jersey, Prentice Hall, 1976. (On Reserve)

-2Recommended Readings: 5) Warriors in White: Some Questions about the Nature and Mission of Military Medicine. Vastyan, Excerpts from Texas Reports on Biology and Medicine: 32: 327-342. 1974. (On Reserve) 6) Soldier, Physician and Moral Man. Veatch, in Case Studies in Medical Ethics. Cambridge, Mass: Harvard University Press, 1977. 7) AIDS: A Growing Threat. Wallis, Time. August 12, 1985. pp. 40-47. (On Reserve) 8) The Ethics of Medical Participation in Capital Punishment by Intravenous Drug Injection. Curran, Casscells, NEJM 302: 226-230. 1980. (On Reserve) 9) Probers Called to See "Needless" Death. Logan, The Washington Post, August 16, 1977. (On Reserve) 10) Recruits to Receive AIDS Tests. Engel, The Washington Post, August 31, 1985. Al

SESSION V: TUESDAY, 24 SEPTEMBER 1985 24 September

1300-1420

1430 -1500 1500 -1600

The Doctor/Patient Relationship in the Military R. Bellamy, COL, MC, USA/E. Dolev, M..D. C. Llewellyn, COL, MC, USA FILM: (1) The Silent Scream Discussion Groups*

Objectives:

1) To gain greater understanding of critical issues discussed in last week's discussion group. 2) To discuss the justification or lack of justification of a physician's using his medical role to influence others to adopt his point of view. 3) To appreciate different approaches to considering whether or not abortion should be permissible. 4) To consider various clinical issues which concern the fetus, such as whether fetal experimentation should be permitted, and what should be done when a fetus is alive after a saline abortion is performed.

Required Reading:

1) But is it a Person? Adler and Carey, Newsweek, January 11, 1982, p. 44. 2) Abortion: Are Medicine and the Law on a Collision Course? Pollner, Medical World News, July 8, 1985, pp. 66+. 3) Abortion and Other Images of Horror. McPherson, Washington Post, February 19, 1985, A-19. 4) An Issue is Born/Fetal Rights Spawn Conflict. Silas, ABA Journal 71:21, 1985.

Recommended Reading:

1) The Nurse-Client Relationship. Maysken, from Moral Problems in Nursing, Rowan and Littlefield, New Jersey, 1982, 57-82. (On Reserve) 2) Fetal Research: The State of the Question. Fletcher and Schulman. The Hastings Center Report, 6-12, April 1985. (On Reserve) 3) Nuclear War, Patriotism, and Medical Ethics. Bruwer, The Pharos, Summer, 1982. (On Reserve) 4) Hill Group Files Brief on Abortions. UPI, Washington Post, A-3, September 4, 1985. 5) Doctors' Dilemmas, Gorovitz, Chps. 5 & 10.

*Attendance is mandatory.

Session VI IDENTIFYING ETHICAL, LEGAL AND SOCIAL ISSUES SESSION VI: TUESDAY, 1 OCTOBER 1985 1 Oct

1400-1450 1500-1600

Objectives:

Abortion and the Fetus P. King, J.D. Discussion Groups*

1) To gain greater understanding of issues discussed in last week's discussion groups 2) To appreciate potential benefits and harms of genetic screening 3) To know arguments for remaining “neutral" and for giving advice when doing genetic counselling 4) To discuss problems arising in genetic counselling when counselling might indicate non-paternity, when risks to the fetus are uncertain, and when relatives would benefit from disclosure but the patient wishes genetic findings kept confidential

Required Readings:

1) The Predictive Power of the New Genetics. Lappe, The Hastings Center Report, October 1984, p. 18-21 2) Ethical Problems in Genetic Counselling. Murray, Ghana Medical Journal, 12:304-309, 1973

Recommended Readings:

1) Problems Behind the Promise: Ethical Issues in Mass Genetic Screening. Murray, The Hastings Center Report 2) AF Academy Discharged Student/Grounded for Bearing Sickle Cell Trait. Knight-Ridder, The Washington Post, Dec 26,1980, p. 45 3) Studying Sickle Cell Trait in Healthy Army Recruits: Should the Research be Done? Howe, Kark, Wright, Clinical Research 31: 119-125, 1983 4) Doctors' Dilemmas. Gorovitz, Chps 6 & 11

*Attendance is mandatory

SESSION VII, TUESDAY, OCTOBER 8, 1985 8 Oct

1400-1450 1500-1600

Objectives:

Genetic Screening and Counseling R. Murray, M.D. Discussion Groups*

1) To gain greater understanding of issues discussed in last week's discussion groups. 2) To identify conflicting values in experimentation using human subjects. 3) To consider ethical dilemmas which could arise for military physicians asked to do research related to medical weaponry. 4) To know arguments for and against conducting research on animals.

Required Reading:

1) Biological Warfare/Lifting the Quarantine. Allman, Science 85, July/August p. 12. 2) "Biomedical Science and War." Sidel, V.W. and Sidel, M., in the Encyclopedia of Bioethics, Reich, Ed., New York, The Free Press, 1977, pp. 1699-1703. 3) "Officials Differ on Forces Training." Tomich, U.S. Medicine, April 15, 1985, p. 1+. 4) "Or Not Emulating the Ostrich: Ethical Concerns About Animal Use that Won'T Go Away." Caplan. 5) "We Need Animals in the Labs." Herndon, Washington Post, Nov. 14, 1981, A2. 6) "Animal Lovers Are Not People Haters." Free, Washington Post, Oct. 17, 1981, A17.

Recommended Reading:

1) "Drug Found That Helps Heart Attack Survivors." Kolata, Science 214:774-775, Nov. 13, 1981. 2) '"Medical Ethics and Biological Warfare." Rosebury, Perspectives in Biology and Medicine, Summer 1963, pp. 512-523. (On Reserve) 3) "On the Morality of Chemical/Biological War." Krickus, J. of Conflict Resolution 9(2):200-210,

June 1965. (On Reserve) 4) "Historical Perspective of Human Values for Animals and Vulnerable People." ten Bensel, The Latham Letter, Winter 1983-84, pp. 6-13, and Spring 1984 pp. 3-6. (On Reserve) 5) "The Ethical Dilemma of Some Classical Animal Experiments." Sechzer, Annals New York Academy of Sciences, 1983, pp. 5-12. (On Reserve) 6) "Animal Experimentation - When Do The Ends Justify The Means?" Garfield, Current Comments, January 30, 1984, pp. 3-13. (On Reserve) 7). Animal Liberation: A Critique. Fox, 1978. (On Reserve) 8) "Has Not An Animal Organs, Disillusions, Senses, Affections, Passions?" Solomon, Psychology Today, 1982, pp. 36-45. (On Reserve) 9) Doctor's Dilemmas. Gorovitz, Chap. 7.

SESSION VIII, TUESDAY, OCTOBER 15, 1985 15 Oct

Objectives:

1400-1415

Experimentation in the Military H. Holloway, COL, MC, USA

1415-1600

Tools for Research: Questions About Animal Rights Film, Class Discussion and Panel R. Simmonds, D.V.M., M.S., Moderator J. Fletcher, Ph.D., E. Howe, M.D., J.D., Panelists

1) To gain greater understanding of issues raised in last week's discussion groups. 2) To consider ethical dilemmas which could arise for military physicians asked to do research related to medical weaponry. 3) To know arguments for and against conducting research on animals.

Recommended Reading: Doctors' Dilemmas, Gorovitz, Ch. 8

ETHICAL, LEGAL, AND SOCIAL ISSUES IN MEDICINE SESSION IX: TUESDAY, 22 OCTOBER 1985 1400 -1450

"A Philosopher on the Wards" S. Gorovitz, Ph.D.

1500 -1600

Discussion Groups*

Objectives:

1) To gain perspective on the ways in which ethical analysis can contribute to clinical care. 2) To gain awareness concerning when it might be useful to obtain an ethics consultant when treating patients. 3) To acquire knowledge of more subtle aspects of patient / doctor communication and their clinical importance. 4) To know means of enhancing one's awareness and sensitivity to patients' feelings.

Required Reading:

1) Hi, Lucille, This is Dr. Gold. Natkins, JAMA 247:2415, May 7, 1982. 2) How to Say It: Terminal Illness, Untimely Death, Congenital Problem, Handicap. Wehlage, Jrnl of the Indiana State Medical Assoc 72:593-595, 1979.

Recommended Reading:

1) Doctor-Patient Communication. Krosch, Negrete (On Reserve) 2) Ethical and Cultural Dimensions of Informed Consent. Cross, Churchill, Annals of Int. Med. 96:110-113, 1982. (On Reserve) 3) Clinical Lessons from Anthropologic and Cross-Cultural Research. Kleinman, Eisenberg, Good, Annals of Int. Med. 88:251-258, 1978. (On Reserve) 4) Folk Medical Beliefs and Their Implications for the Care of Patients. Snow, Annals of Int. Med. 81:82-96, 1974. (On Reserve) 5)Sociologic Influences on Decision-Making by Clinicians. Eisenberg, Annals of Int. Med. 90:957-964, 1979. (On Reserve) 6) Can Ethics Provide Answers? Rachels, Hastings Center Report, June 1980, pp. 22-40. (On Reserve) 7)Ethics Rounds in a Children's Medical Center: Evaluation of a Hospital-Based Program for Continuing Education in Medical Ethics. Levine, Scott, Curran, Pediatrics 60:202208, 1977. (On Reserve) 8) Doctors' Dilemmas. Gorovitz, Chps. 9 and 12.

The lecture will be held in Lecture Room D, Building C * Discussion group will be held around tables in cafeteria marked by letter

SESSION X, TUESDAY, 29 OCTOBER 1985 1400 -1415 1420 -1450 1450 -1500 1500 -1530 1530 -1600

"Coercive Influences in Medicine" R. Rahe, CAPT, MC, USN Dramatic Presentation: "Frankenstein" Jon Spelman Intermission "Frankenstein" (continued) Panel - E. Dolev, M.D./C. Llewellyn, COL, MS, USA and Class Discussion

Objectives:

1) To learn a means of evaluating one's approach to ethical decision making. 2) To be aware of cognitive versus non-cognitive approaches to decision making. 3) To consider moral biases in favor of utility one may already have acquired. 4) To better appreciate ways in which the processes of becoming a physician and being a physician can affect your values and emotions. 5) To experience how viewing a play can stimulate greater awareness of your own and other persons' and patients' feelings.

Required Readings:

1) Cognitive Moral Development Theory and Moral Decisions in Health Care. Allen, D.F., and Fowler, M.D., Law, Medicine and Health Care, Feb. 1982, pp. 19-23.

Recommended Reading:

1) Who Shall be Saved? An African Answer. Kilner, J.F. The Hastings Center Report, June 1984, pp. 18-22. On reserve. 2) Triage: Endgame Realities. Smith, G.P., J. Contemporary Health, Law and Policy 1(1):143-151, 1985. On reserve. 3) Allocation of Resources: The Artificial Heart. Green, H.P., Gorovitz, S, The Hastings Center Report, October 1984, pp. 13-17. On reserve. 4) Doctors' Dilemmas, Gorovitz, Chap. 13.